Delirium in the Critically Ill Child: Assessment and Sequelae

Psychological Health of the Adolescent Transplant Recipient

BACKGROUND

Solid organ transplant recipients experience a period of unique vulnerability during adolescence, when normative developmental changes intersect with health-related variables to influence psychological health.

METHODS

This article builds on previous reviews of psychological health in solid organ transplant recipients and proposes opportunities for clinical intervention during adolescence.

RESULTS

Transplant recipients often experience neurocognitive changes, particularly with respect to executive functions, that impact health management tasks and autonomous care. Recipients should be monitored for the development of anxiety, depression, and posttraumatic stress symptoms during adolescence, which in turn can negatively impact adherence to immunosuppression. Recent research in posttraumatic growth and resiliency factors may represent a promising avenue of intervention, leveraging normative developmental processes during this time period.

CONCLUSIONS

As pediatric transplant providers, adolescence represents a developmental period for targeted interventions to foster adjustment and adherence and promote a successful transition to adult care.

Non-pharmacological interventions for delirium in the pediatric population: a systematic review with narrative synthesis

BACKGROUND

Delirium is a serious complication experienced by hospitalized children. Therefore, preventive management strategies are recommended for these patients. However, comprehensive analyses of delirium interventions in children remain insufficient. Specifically, this systematic review aimed to summarize non-pharmacological interventions for pediatric delirium, addressing the urgent need for a comprehensive understanding of effective strategies. We also explored frequently measured outcome variables to contribute evidence for future research on delirium outcomes in children.

METHODS

This systematic review searched articles from PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica databases. The eligibility criteria were formed under the population, intervention, comparator, outcome, and study design framework. Studies were included if they involved (1) children aged under 18 years receiving hospital care, (2) non-pharmacological delirium interventions, (3) comparators involving no intervention or pharmacological delirium interventions, and (4) outcomes measuring the effectiveness of non-pharmacological delirium interventions. Only peer-reviewed articles published in English were included.

RESULTS

Overall, 16 studies were analyzed; of them, 9 assessed non-pharmacological interventions for emergence delirium and 7 assessed interventions for pediatric delirium. The intervention types were grouped as follows: educational (n = 5), multicomponent (n = 6), and technology-assisted (n = 5). Along with pediatric and emergence delirium, the most frequently measured outcome variables were pain, patient anxiety, parental anxiety, pediatric intensive care unit length of stay, agitation, analgesic consumption, and postoperative maladaptive behavior.

CONCLUSIONS

Non-pharmacological interventions for children are effective treatments without associated complications. However, determining the most effective non-pharmacological delirium intervention for hospitalized children based on current data remains challenging.

Risk factors and incidence of postoperative delirium after cardiac surgery in children: a systematic review and meta-analysis

Delirium, a form of acute cerebral dysfunction, is a common complication of postoperative cardiac surgery in children. It is strongly associated with adverse outcomes, including prolonged hospitalization, increased mortality, and cognitive dysfunction. This study aimed to identify risk factors and incidence of delirium after cardiac surgery in children to facilitate early identification of delirium risk and provide a reference for the implementation of effective prevention and management. A systematic literature search was conducted in PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang for studies published in English or Chinese from the inception of each database to November 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. A total of twelve studies were included in the analysis, with four studies classified as overall low risk of bias, seven studies as moderate risk of bias, and one study as high risk of bias. The studies reported 39 possible predictors of delirium, categorized into four broad groups: intrinsic and parent-related factors, disease-related factors, surgery and treatment-related factors, and clinical scores and laboratory parameters. By conducting qualitative synthesis and quantitative meta-analysis, we identified two definite factors, four possible factors, and 32 unclear factors related to delirium. Definite risk factors included age and mechanical ventilation duration. Possible factors included developmental delay, cyanotic heart disease, cardiopulmonary bypass time, and pain score. With only a few high-quality studies currently available, well-designed and more extensive prospective studies are still needed to investigate the risk factors affecting delirium and explore delirium prevention strategies in high-risk children.

Risk Factors and Nomogram Model of Postoperative Delirium in Children with Congenital Heart Disease: A Single-Center Prospective Study

Delirium is a common postoperative complication in children with congenital heart disease, which affects their postoperative recovery. The purpose of this study is to explore the risk factors of delirium and construct a nomogram model to provide novel references for the prevention and management of postoperative delirium in children with congenital heart disease. 470 children after congenital heart surgery treated in the cardiac intensive care unit (CICU) of Shanghai Children's Medical Center were divided into a model and a validation cohort according to the principle of 7:3 distribution temporally. Then, the delirium-related influencing factors of 330 children in the training cohort were analyzed, and the nomogram model was established by a combination of Lasso regression and logistic regression. The data of 140 children in the validation cohort were used to verify the effectiveness of the model. Multivariable logistic regression analysis showed that age, disease severity, non-invasive ventilation after extubation, delayed chest closure, phenobarbital dosage, promethazine dosage, mannitol usage, and elevated temperature were independent risk factors for postoperative delirium. The area under the receiver operating characteristic curve (AUC) of the nomogram model was 0.864 and the Brier value was 0.121. Regarding the validation of the model's effect, our results showed that 51 cases were predicted by the model and 34 cases actually occurred, including 4 cases of false negative and 21 cases of false positive. The positive predictive value of the model was 58.8%, and its negative predictive value was 95.5%. The nomogram model established in this study showed acceptable performance in predicting postoperative delirium in children with congenital heart disease.

Inter-Rater Reliability of Delirium Screening of Infants in the Cardiac ICU: A Prospective, Observational Study

OBJECTIVES

To determine the inter-rater reliability (IRR) of the Cornell Assessment for Pediatric Delirium (CAP-D) in infants admitted to a cardiac ICU (CVICU) and to explore the impact of younger age and mechanical ventilation on IRR.

DESIGN

Prospective cross-sectional study of delirium screening performed by bedside CVICU nurses. We collected data from September 2020 to April 2021. We evaluated IRR with intraclass correlation coefficient (ICC) one-way random effects and Fleiss kappa for multiple raters.

SETTING

Eighteen-bed academic pediatric CVICU.

PARTICIPANTS

Subjects: Infants 1 day to 1 year old admitted to the CVICU, stratified in two age groups (≤ 9 wk and 9 wk to < 1 yr). Exclusion criteria were patients' immediate postoperative day, State Behavioral Scale score less than or equal to -2, or at risk for hemodynamic instability with assessment. Raters: CVICU nurses working in the unit during study days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Groups of four raters performed 91 assessments, a total of 364 CAP-D screens. Forty-five of 91 (49%) were in patients less than or equal to 9 weeks old and 43 of 91 (47%) in mechanically ventilated patients. Sixty-eight of 81 nurses (81%) participated. In infants less than or equal to 9 weeks old, ICC was 0.59 (95% CI 0.44-0.71), poor to moderate reliability, significantly lower than the ICC in infants greater than 9 weeks and 0.72 (95% CI 0.61-0.82), moderate to good reliability. In mechanically ventilated infants, ICC was 0.5 (95% CI 0.34-0.65), poor to moderate reliability, significantly lower than the ICC in nonmechanically ventilated infants and 0.69 (95% CI 0.57-0.8), moderate to good reliability. Fleiss kappa for all infants was 0.47 (95% CI 0.34-0.6), slight to fair agreement. Use of anchor points did not improve reliability.

CONCLUSIONS

In the youngest, most vulnerable infants admitted to the CVICU, further evaluation of the CAP-D tool is needed.

Construction and validation of an early prediction model of delirium in children after congenital heart surgery

BACKGROUND

Delirium often occurs in children with congenital heart disease in the early postoperative period, which is not conducive to the rehabilitation and prognosis. There is little evidence to prove the effectiveness and safety of drug treatment of delirium in children, and the prevention has become an important topic. The purpose of this study is to analyze the early risk factors of delirium in children after congenital heart surgery, establish a nomogram prediction model, and explore the application efficiency of the model, so as to provide reference for early prevention of delirium.

METHODS

A total of 362 children treated in the cardiac intensive care unit (CICU) of Shanghai Children's Medical Center after congenital heart surgery from February 15 to April 15, 2021 were enrolled for the construction of the model. Bedside nurses who received unified training used the Cornell Assessment of Pediatric Delirium (CAPD) to evaluate delirium and recorded sixteen preoperative- and intraoperative-related influencing factors. A nomogram prediction model was created using multivariate logistic regression. The prediction effect of the model was evaluated by C-index and Brier value, and 96 children from April 16 to May 15, 2021 were included for effect verification. The model's effectiveness was validated by comparing the occurrence of delirium in children predicted by the model with the actual occurrence.

RESULTS

Multivariate logistic regression analysis showed that male gender [odds ratio (OR) =1.786, 95% confidence interval (CI): 1.018-3.134, P=0.043], age <6.5 months (OR =0.224, 95% CI: 0.126-0.399, P=0.000), disease severity ≥4 points (OR =6.955, 95% CI: 3.564-13.576, P=0.003), and operation time ≥148 min (OR =2.401, 95%CI: 1.336-4.315, P=0.000) were independent risk factors for delirium in children after cardiac surgery. The C-index of the nomogram prediction model was 0.808, sensitivity was 76.1%, specificity was 70%, and the Brier value was 0.142. The validation of the model showed that the model predicted 20 cases and the actual occurrence was 20 cases, of which 8 cases were false negative and 8 cases were false positive, and the sensitivity, specificity, and accuracy of the model were 60%, 89.5%, and 83.3%, respectively.

CONCLUSIONS

The prediction model constructed in this study could provide early prediction of the occurrence of delirium in children after congenital heart surgery to a certain extent.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Italian Version of the Cornell Assessment of Pediatric Delirium: Evaluation of the Scale Reliability and Ability to Detect Delirium Compared to Pediatric Intensive Care Unit Physicians Clinical Evaluation

BACKGROUND

Delirium is an acute brain dysfunction associated with increased length of hospitalization, mortality, and high healthcare costs especially in patients admitted to the pediatric intensive care unit (PICU). The Cornell Assessment of Pediatric Delirium (CAPD) is a screening tool for evaluating delirium in pediatric patients. This tool has already been used and validated in other languages but not in Italian.

OBJECTIVES

To test the reliability of the Italian version of the CAPD to screen PICU patients for delirium and to assess the agreement between CAPD score and PICU physician clinical evaluation of delirium.

METHODS

Prospective double-blinded observational cohort study of patients admitted to a tertiary academic center PICU for at least 48 h from January 2020 to August 2021. We evaluated intra- and inter-rater agreement using the Intraclass Correlation Coefficient (ICC). The ability of the scale to detect delirium was evaluated by comparing the nurses' CAPD assessments with the clinical evaluation of a PICU physician with expertise in analgosedation using the area under the ROC curve (AUC).

MEASUREMENTS AND MAIN RESULTS

Seventy patients were included in the study. The prevalence of pediatric delirium was 54% (38/70) when reported by a positive CAPD score and 21% (15/70) when diagnosed by the PICU physician. The CAPD showed high agreement levels both for the intra-rater (ICC 1 0.98, 95% CI: 0.97-0.99) and the inter-rater (ICC 2 0.93, 95% CI: 0.89-0.96) assessments. In patients with suspected delirium according to the CAPD scale, the observed sensitivity and specificity of the scale were 0.93 (95% CI: 0.68-1.00) and 0.56 (95% CI: 0.42-0.70), respectively. The AUC observed was 0.75 (95% CI: 0.66-0.8490).

CONCLUSION

The Italian version of the CAPD seems a reliable tool for the identification of patients at high risk of developing delirium in pediatric critical care settings. Compared to the clinical evaluation of the PICU physician, the use of the CAPD scale avoids a possible underestimation of delirium in the pediatric population.

Implementation of the "awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility" bundle in the pediatric intensive care unit of tertiary hospitals in southwestern China: a cross-sectional survey

Objective

To investigate management and implementation of the “awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility” (ABCDE) bundle in the pediatric intensive care unit (PICU) in southwestern China

Methods

A self-designed questionnaire for determining implementation of the ABCDE bundle was distributed to healthcare professionals in the PICU. Multiple linear regression was used to analyze results.

Results

A total of 270 questionnaires were collected. There was no significant difference in the awareness of the ABCDE bundle rate among Sichuan, Guizhou, and Yunnan workers. Only dynamic adjustment of drug dose accounted for more than half (55.5%) of “frequent implementation” and “general implementation”, followed by implementation of sedation assessment, pain assessment, and spontaneous breathing trials (46.4%, 39.3%, and 35.6%, respectively). A total of 80.4% of healthcare professionals never performed screening of delirium. Multivariate analysis showed that the healthcare professionals’ scores of ABCDE bundle behavior significantly differed regarding awareness of the ABCDE bundle, years of work at the hospital, the region of hospitals, and occupational category.

Conclusion

Implementation of the ABCDE bundle in the PICU in southwestern China is not sufficient. Existing problems need to be identified and a standardized sedation and analgesia management model needs to be established.

The Impact of Implementing a “Pain, Agitation, and Delirium Bundle” in a Pediatric Intensive Care Unit: Improved Delirium Diagnosis

Delirium is associated with significant negative outcomes, yet it remains underdiagnosed in children. We describe the impact of implementing a pain, agitation, and delirium (PAD) bundle on the rate of delirium detection in a pediatric intensive care unit (PICU). This represents a single-center, pre-/post-intervention retrospective and prospective cohort study. The study was conducted at a PICU in a quaternary university-affiliated pediatric hospital. All patients consecutively admitted to the PICU in October and November 2017 and 2018. Purpose of the study was describe the impact of the implementation of a PAD bundle. The rate of delirium detection and the utilization of sedative and analgesics in the pre- and post-implementation phases were measured. A total of 176 and 138 patients were admitted during the pre- and post-implementation phases, respectively. Of them, 7 (4%) and 44 (31.9%) were diagnosed with delirium (p < 0.001). Delirium was diagnosed in the first 48 hours of PICU admission and lasted for a median of 2 days (interquartile range [IQR]: 2–4). Delirium diagnosis was higher in patients receiving invasive ventilation (p < 0.001). Compliance with the PAD bundle scoring was 79% for the delirium scale. Score results were discussed during medical rounds for 68% of the patients in the post-implementation period. The number of patients who received opioids and benzodiazepines and the cumulative doses were not statistically different between the two cohorts. More patients received dexmedetomidine and the cumulative daily dose was higher in the post-implementation period (p < 0.001). The implementation of a PAD bundle in a PICU was associated with an increased recognition of delirium diagnosis. Further studies are needed to evaluate the impact of this increased diagnostic rate on short- and long-term outcomes.

Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care

OBJECTIVES

The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity.

DESIGN

This is a prospective observational study.

SETTING

The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital.

PATIENTS

The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h.

INTERVENTIONS

No interventions were provided in the study.

MEASUREMENTS AND MAIN RESULTS

Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01).

CONCLUSIONS

Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.

Delirio en niños críticamente enfermos

El delirio en pacientes críticos es una condición médica que afecta tanto a adultos como a niños; en ambas poblaciones implica graves complicaciones como estancia hospitalaria prolongada, alto riesgo de muerte y deterioro cognitivo a largo plazo, así como mayores costos económicos en cuanto a la prestación de servicios de salud. La principal dificultad de esta condición en la población pediátrica es su adecuado reconocimiento, ya que puede presentarse en edades muy tempranas, incluso en niños lactantes, cuando sus signos y síntomas pueden confundirse o superponerse con otras patologías, tales como el síndrome de abstinencia. En consecuencia, en estos casos el uso de herramientas diagnósticas puede ser una labor compleja que implica múltiples dificultades.Antes de 2011 no había muchos estudios que abordaran la evaluación del delirio en niños. Sin embargo, ese mismo año se estableció la primera escala desarrollada específicamente para el monitoreo de pacientes en unidades de cuidado intensivo pediátrico, lo que llevó a un aumento significativos del número de casos de delirio en niños menores de 5 años críticamente enfermos; esta situación hizo que los pediatras se interesaran más en estudiar esta importante patología.La presente reflexión, basada en una revisión de la literatura, busca actualizar el amplio espectro fisiopatológico del delirio en niños críticamente enfermos y, de esta forma, mejorar su tamizaje, diagnóstico e intervenciones terapéuticas tempranas en todas las edades pediátricas, incluso en menores de 5 años.

Not just to survive but to thrive: delirium in the pediatric cardiac ICU

PURPOSE OF REVIEW

Pediatric delirium has recently been recognized to occur frequently in the pediatric general and cardiac ICU. The purpose of this review is to highlight recent data on the prevalence, prevention, and management of this condition.

RECENT FINDINGS

Pediatric delirium occurs in the pediatric cardiac ICU (PCICU) in as many as 67% of patients. Validated screening tools are now available to assist clinicians in the diagnosis of this condition. Research has shown a growing relationship between benzodiazepines, mainstays in the realm of sedation, and delirium. The full spectrum of risk factors has yet to be clearly elucidated. After normalization of the ICU environment, antipsychotics are infrequently required for treatment. While pediatric delirium has been associated with increased length of stay and cost, long-term morbidities are unknown at this time.

SUMMARY

Application of bundles to normalize the PCICU environment may lead to decreased incidence of pediatric delirium. Multiinstitutional studies are indicated to further delineate optimal bundles, stratify treatment strategies, and investigate long-term morbidity in pediatric delirium.

Traduction et validation de l’échelle d’évaluation du delirium pédiatrique de Cornell en version française

Objectif : Le delirium est commun chez les patients de soins intensifs pédiatriques (SIP), mais sous-reconnu par les cliniciens en l’absence d’une échelle de dépistage de delirium pédiatrique. L’objectif de cette étude était donc de traduire et de valider l’échelle d’évaluation du delirium pédiatrique de Cornell en version française.

Patients et méthodes : Pour la traduction, la méthode reconnue de rétrotraduction a été utilisée. L’échelle Cornell Assessment of Pediatric Delirium a été traduite de l’anglais vers le français par une traductrice et un médecin francophones. Les deux versions ont été mises en commun et harmonisées, puis cette version a été rétrotraduite en anglais par un médecin anglophone. Cette traduction a ensuite été comparée à la version source par les auteurs originaux qui ont pprouvé la traduction. La version française finale de l’échelle a été validée sur 25 patients admis dans notre unité médicochirurgicale de SIP de 32 lits. Chaque patient a été évalué de manière indépendante par deux infirmières. La reproductibilité interobservateur a été mesurée par un coefficient de Kappa.

Résultats : Cinquante mesures ont été obtenues au cours des 25 évaluations. La concordance interobservateur était presque parfaite, avec un coefficient de Kappa de 0,92. Le temps médian nécessaire pour compléter l’échelle était de 51 secondes.

Conclusion : La version française de l’échelle d’évaluation du delirium pédiatrique de Cornell est valide et reproductible dans un milieu de SIP.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients

OBJECTIVES

To determine and quantify risk factors for postoperative pediatric delirium.

DESIGN

Single-center prospective cohort study.

SETTING

Twenty-two bed PICU in a tertiary care academic medical center in Germany.

PATIENTS

All children admitted after major elective surgery (n = 93; 0-17 yr).

INTERVENTIONS

After awakening, children were screened for delirium using the Cornell Assessment of Pediatric Delirium bid over a period of 5 days. Demographic and clinical data were collected from the initiation of general anesthesia.

MEASUREMENTS AND MAIN RESULTS

A total of 61 patients (66%) were delirious. Younger children developed delirium more frequently, and the symptoms were more pronounced. The number of preceding operations did not influence the risk of delirium. Total IV anesthesia had a lower risk than inhalational anesthesia (p < 0.05). Duration of anesthesia was similar in all groups. Patients with delirium had a longer duration of mechanical ventilation in the PICU (p < 0.001). Significant differences in cumulative doses of various medications (e.g., sedatives, analgesics, and anticholinergics) were noted between groups; these differences were independent of disease severity. Invasive catheters and respiratory devices (p < 0.01) as well as infections (p < 0.001) increased risk of delirium.

CONCLUSIONS

A high prevalence of delirium was noted in the PICU, and several perioperative risk factors were identified. Our data may be a base for development of strategies to prevent and treat postoperative delirium in children.

Cognitive and Behavioral Consequences of Pediatric Delirium: A Pilot Study

OBJECTIVES

To investigate the long-term impact of postoperative delirium in children.

DESIGN

Single-center point prevalence study.

SETTING

Twenty-two bed PICU.

PATIENTS

Forty-seven patients 1-16 years old.

INTERVENTIONS

Standardized neuropsychologic follow-up investigation after a mean time of 17.7 ± 2.9 months after PICU discharge.

MEASUREMENTS AND MAIN RESULTS

Pediatric delirium did not have significant long-term impact on global cognition, executive functions, or behavior. Severity of delirium did not influence the outcome. Different predictors were identified for later cognitive functioning, executive functions, and behavioral problems. Younger age was confirmed to be a relevant risk factor for delirium as well as for the cognitive and behavioral outcome.

CONCLUSIONS

Contrary to the findings in adults, there was no clear association between pediatric delirium and long-term cognition or behavior in this cohort. However, this is a first pilot study with several limitations that should promote more comprehensive prospective trials.